LICENSURE INSTRUCTIONS Mississippi Department …

Office of Teaching and Leading Division of Educator Licensure Form LA Revised February 2021

LICENSURE INSTRUCTIONS

Mississippi Department of Education Office of Educator Licensure P. O. Box 771 Jackson, MS 39205-0771 (601) 359-3483

Please read directions carefully:

1. All educators are encouraged to apply for licensure requests online through the Educator Licensure Management System (ELMS). ELMS is accessible through the Mississippi Department of Education (MDE) website at . Your ELMS account will provide you with your Educator ID number and allow you to upload supporting documents for your application. When applying online, remember that supporting documents from the Licensure Checklist must still be mailed to the address above to complete licensure request.

If submitting a paper application, complete and return the Licensure Application (pp. 2-3) with all other required documents as a single, complete packet to the address above. A complete packed includes an Application, plus all documents listed under your licensure category from the Licensure checklist. Applications that arrive without supporting documents will be considered incomplete, and the educator will be mailed a "requirements" letter, stating which documents are needed to process the licensure request.

The Licensure Application, Licensure Checklist and all referenced forms in the License Checklist can be obtained by visiting unless otherwise specified.

2. All transcripts from all institutions must be submitted in a sealed envelope(s) bearing the seal or signature of the registrar. It should be mailed to you and may be stamped "student issued." Do not open the sealed envelope. The Office of Educator Licensure also accepts electronic transcripts through eScripSafe or Clearinghouse Transcript Exchange if the institution at which the degree was earned or acceptable coursework was taken utilizes the services offered by one of the organizations noted here. This is the fastest, most secure way to get your transcripts to the Office of Educator Licensure.

3. All Praxis test takers who test in the state of MS test score results are automatically reported to the MDE. To ensure successful retrieval of scores automatically reported to the MDE, please be sure to include your full and correct social security number. If you test out of state, please designate the MDE as a score recipient during the test registration process. If you do not request your scores be sent electronically to MDE, you can submit an official paper copy of all pages of your score report to the Office of Educator Licensure.

For additional information regarding educator licensure, please visit the Mississippi Department of Education, Office of Educator Licensure webpage:



Form LA, revised February 2021, page 2

LICENSURE APPLICATION (Must be LEGIBLY completed and submitted with all licensure requests)

APPLICANT INFORMATION

Social Security Number: _________________ Email Address: ___________________

Legal Name: _______________ ____________ ____________ ________________

Last

First

Middle

Maiden

Address: __________________________________________ ________________

Street/P.O. Box

Apt#

____________________________________ City

_________ State

___________ Zip

Phone Number: ____________________ Birthdate: _____________ Gender: _____

Ethnicity: (Ethnicity information is used for statistical purposes and to provide information required by

the U.S. Department of Education in accordance with applicable federal regulations. Your cooperation in

providing this information is appreciated.)

American Indian

Alaskan Native

Asian

Black: non-Hispanic

White: non-Hispanic Hispanic

Pacific Islander

Other

Military Experience (Check, if applicable)

Army

USAF Navy

USMC Reserve MSNG Coast Guard

LICENSURE REQUEST

Class of license for which you are applying:

A (Bachelor) AA (Master) AAA (Specialist) AAAA (Doctorate) Check here if you are applying for a class upgrade at this time

Type of License (see Licensure Checklist for descriptive information)

Approved Program/Teacher Education Route Subject Area(s):_________________________

Alternate Route

Subject Area(s):_________________________

Supplemental Endorsement

Subject Area(s):_________________________

Administrator License (select license level)

Non-Practicing

Entry

Career

School Business Administrator (select)

Three Year

Five Year

District Superintendent License (select)

Three Year

Five Year

Duplicate

Reciprocity

Renewal/Reinstatement

JROTC

Form LA, revised February 2021, page 3

This Section Must Be Completed by Applicants for Licensure in the Areas of Psychometry and/or School Psychologist Only: The undersigned applicant for licensure in the area(s) of psychometrist and/or school psychologist hereby affirms that the aforementioned titles shall only be used when they are employed by or under contract with a school district and practicing in school or educational settings" (emphasis added). Explicitly, Mississippi Code Annotated ? 73-31-27, paragraph two (2), states, "Individuals certified by the Mississippi State Department of Education may use appropriate titles such as "school psychologist," "certified school psychologist," "educational psychologist" or "psychometrist" only when they are employed by or under contract with a school district and practicing in school or educational settings" (emphasis added). Furthermore, your signature serves as confirmation of your understanding that your scope of practice as a psychometrist and/or school psychologist is limited to these settings when holding only a license granted and issued by the Mississippi Department of Education, which does not include work in a private practice type setting, by this statute.

Signature of Applicant: _____________________________________________________

CHARACTER DETERMINATION

Check "yes" or "no" to the left of each question Yes No Are you currently addicted to or dependent on alcohol?

Yes No Are you currently addicted to or dependent on habit forming drugs?

Yes No Are you a habitual user of narcotics, barbiturates, amphetamines, hallucinogens, or other

.

drugs having similar effects?

Yes No Have you been convicted of, or pled guilty to, a felony as defined by federal or state law?*

.

(For the purpose of this question, a "guilty plea" includes a please of guilty, entry of a plea of .

nolo contendere, or entry of any order granting pretrial or judicial diversion.)

Yes No Have you been convicted of, or pled guilty to, a sex offense as defined by federal or state law?* . (For the purpose of this question, a "guilty plea" includes a please of guilty, entry of a plea of . nolo contendere, or entry of any order granting pretrial or judicial diversion.)

Yes No Are you currently on probation or post-release supervision for a felony or sex offense as . defined by federal or state law?*

Yes No Have you had a certificate/license denied, suspended, and/or revoked by MS or another state

.

or have you voluntarily surrendered a certificate/license?

If you answered "yes" to any of the above provide, on a separate sheet of paper, the specifics or an explanation for the response. If you elect not to provide specifics or if such an explanation is insufficient, a confidential investigation will be initiated. *If you answered "yes" submit official copies of court records including disposition of case.

ACKNOWLEDGEMENT

I acknowledge that securing or attempting to secure a license by fraud or deceit will result in denial of this application or suspension of the license.

Signature: _________________________________ Date: ____________________

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